PST-PC Appendix Introducing PST-PC to the Patient in Session 1 Checklist 1. Structure of PST-PC Treatment 6 Visits Today Visit: 1-hour; Visits 2-8: 30-minutes Weekly and Bi-weekly Visits Teach problem solving skills Work through at least one problem per week Work on homework between visits 2. Establish that Symptoms are Due to Depression Assure understanding that depression is causing symptoms Collect brief list of key depressive symptoms As necessary, use mind/body explanation State that will track symptoms during treatment 3. Link Between Problems, Depression and PST-PC Depression is often caused, or made worse, by the problems of living Worsening depression interferes with problem solving: Vicious cycle / Downward spiral PST-PC strengthens problem-solving skills Improved problem-solving lifts mood Improvement follows action 4. Problem-Solving Orientation Problems are a normal, predictable part of living Problems are not unfair, and should be expected Negative mood is a cue that problems exist Some degree of control can almost always be achieved Taking action alone will cause mood to improve 5. The Seven Stages (Steps) of PST-PC 1. Clarifying and defining the problem 2. Establishing objective achievable goal 3. Solution alternatives: Brainstorming 4. Decision guidelines: Pros and Cons 5. Choosing the preferred solution(s) 6. Implementing the solution(s) 7. Evaluating the outcome 6. Activity Scheduling Depression stops people from doing enjoyable things Fewer enjoyable things causes and worsens depression Vicious cycle / Downward spiral We will focus on increasing enjoyable activities each day 7. Problem List Generation Focus on current problems Allow patient to first spontaneously report current problems Systematically review categories from problem worksheet
PROBLEM SOLVING TREATMENT FOR DEPRESSION PATIENT HANDOUT PST-PC Treatment: Brief: 6 sessions 1 hour today, then 30 minutes. Practically focused on current, real-life problems. Collaborative between patient and therapist. How It Works: Depression is often caused by problems in life. PST-PC helps patients begin to exert control over the problems in their life. Regaining control over problems improves mood and helps patients feel better. Depression is very common. It s often caused by problems of living. We all encounter problems in our lives, big and small, everyday. It s a normal part of living. Having problems isn t unfair, really; it s just a part of the way life is. If we let problems pile up unresolved, however, it can become overwhelming and lead us to feeling depressed. People who are depressed can learn ways of dealing with these problems. Using problem-solving skills, people can learn to cope better with their problems and feel better as a result. We can almost always exert some degree of control over our problems. And, if we re able to tackle problems as they arise, it will decrease the likelihood that we become, or stay, depressed. A depressed mood is a signal that there are problems in one s life that need attending to and we can use this as a cue to take action. To stop and think: what problem might be troubling me? We can then put our problem-solving skills to work and begin to feel better. Problem-solving is a systematic, commonsense way of sorting out problems and difficulties. If you can learn how to problem-solve easily, you can lessen your depressive symptoms and feel better without having to take pills. In problem solving treatment, the therapist explains the details of the treatment and provides encouragement and support, but the ideas, plans, and action come from you. Problem solving skills will not only be useful now, but can also help you when future problems arise. 1
PST-PC has 7 important stages: 1. Write down a clear description of one problem to work on. What is the problem about? When does the problem occur? Where? Who is involved? Try to break up complicated problems into several smaller ones and consider each one separately. 2. Set a realistic goal. What would you like to happen? Choose a clear and achievable goal. 3. Brainstorm. List as many solutions as you can think of. Don t rule anything out. 4. Consider the advantages and disadvantages (pros and cons) for each potential solution. What are the benefits of each solution? What are the difficulties or obstacles? 5. Choose the solution that seems the best. Which solution seems the most feasible and has the least impact on your time, effort, money, other people s effort, etc.? 6. Develop an Action Plan. Write down exactly what you will do and when. 7. Review and evaluate your progress. Make needed changes. How has this helped your mood? Problem-solving may not solve all of your difficulties, but it can teach you a better way to deal with them. As you begin to feel more in control of your problems, your mood will feel better too. 2
PATIENT HANDOUT Why is it Important to Do More Pleasurable Activities? When people get depressed they don t feel up to doing the kinds of things they typically enjoy. By doing fewer enjoyable things they begin to feel even worse. As they feel worse, they do even less, and get caught up in a vicious cycle of doing less and less and feeling worse and worse. FEEL BAD DO LESS As part of problem solving treatment we will help you set a goal of doing at least one pleasurable activity each day. In other words, arranging to provide yourself with a treat each day. Sometimes working on the problem of too few pleasant activities can be a simple and effective way to start to learn problem solving skills. The positive benefits are: (a) (b) You can use problem-solving steps to help with pleasurable activities; You will start to assert control over your life in a positive and beneficial way; and (c) Your success with doing pleasurable things will give you motivation to tackle some of the more difficult problems in your life.
Materials Needed for Introducing PST-PC: Provide the patient with: (1) A completed copy of the session's PST-PC Worksheet (Appendix 6) (Completed by the therapist; photocopy for the patient) (2) Problem-Solving Guidelines handout (Appendix 4) (3) Extra PST-PC Worksheet for independent problem solving between sessions. (4) Activity Scheduling handout (Appendix 4). (5) A copy of the Problem List Worksheet (Appendix 5). The Problem-Solving Worksheet Most of the work during the problem solving treatment session can be recorded on the Problem-Solving Worksheet. The worksheet outlines the seven stages of PST-PC and allows enough space to record the various problems, goals, solutions, etc. derived from the session. Early in treatment (e.g. Session 1) the therapist takes primary responsibility for recording the information, with the patient following along with a blank worksheet. As treatment progresses, the therapist gradually turns over to the patient more of the responsibility for completing the worksheet. For example, during Session 2 the patient fills out their own worksheet along with the therapist and is provided guidance in doing so. During subsequent sessions the patient takes primary responsibility for
completing the worksheet, although the therapist may certainly provide guidance and cueing as needed. It may be necessary to emphasize to patients who are reluctant to use the worksheet that the goal of PST-PC is not to create paperwork for them but to teach them a systematic method to use for solving their problems. The worksheet is a tool to help them do this but is not an end in itself. Therefore, extra copies of the worksheet should always be provided to the patient at the end of each session. Tasks and Materials Needed for PST-PC Session 1: Time: 60 minutes. The following tasks should be completed during this session. Recommendations for the time required to complete each task are also provided. (1) Explain the structure of PST-PC Treatment (2 minutes). (2) Establish that symptoms are related to depression (2-5 minutes). (3) Explain the link between problems and depressive symptoms and the rationale for problem-solving treatment (2-5 minutes); (4) Establish an appropriate problem solving orientation (5 minutes); (5) Describe the seven stages of the problem-solving process (5 minutes); (6) Describe the rationale and importance of activity scheduling (2 minutes); (7) Compile a list of problems (10 minutes); and (8) Illustrate the problem-solving process by working it through on a specific problem (30 minutes).
Conducting PST-PC Sessions Two through Six SESSION 2: Time: 30 minutes. The tasks for this session are to: (1) review the patient s progress and reinforce success and continued effort; (2) remind the patient of the problem solving treatment model; (3) guide and support the patient in acquiring and using problem-solving skills; and (4) facilitate a positive problem-solving attitude. The session should begin with a review of progress on the homework tasks. This is actually Stage 7 of problem solving treatment, Evaluating the Outcome. In early phases of treatment the patient s low mood may hamper their problem-solving ability. It is important therefore for the therapist to give the patient verbal support and reassurance in order to combat demoralization. Often the patient magnifies difficulties in implementing solutions and overstates lack of progress. Such attitudes must be disconfirmed by providing the patient with evidence of success based on what they have actually accomplished. Self-reward may be suggested as being useful to reinforce success. For example, going to the movies (an enjoyable activity) after success in achieving a goal that was difficult to attain. The therapist should be careful not to spend so much time reviewing progress that time is limited for additional problem-solving. Typically, five minutes or less should be
devoted to the review, unless significant obstacles were encountered in completing the homework, or major new problems have arisen. The remainder of the session should be spent in problem-solving and planning tasks to be accomplished before the next session. These tasks may be linked to the previous problem if it has not been resolved, or to a new problem. At times, the problem from the previous session may not have been completely resolved, but due to obstacles outside of the patient s control, or due to the protracted nature of the solution, further discussion during the current session is not warranted. In such a case, it is reasonable to address other problems after reminding the patient to continue their efforts on the previous problem. In fact, when conducting the review of homework, whether during Session 2 or subsequent sessions, the therapist should review all problems addressed previously to encourage continued effort throughout treatment. This does not need to be a lengthy discussion. The therapist should simply remind the patient of their previous tasks, and if the problem is unresolved, encourage continued effort toward achieving their solutions. Of course, if new or ongoing obstacles are encountered the previous problem may be used again for the current problem solving session. Materials for Session 2: Provide the patient with: (1) PST-PC Worksheet: Patient follows along with the therapist, using his or her own PST- PC Worksheet in session and is provided a copy of the completed worksheet from the therapist (photocopied). (2)) Extra PST-PC Worksheet for independent problem solving between sessions.
SESSIONS 3 THROUGH 5: Time: 30 minutes. The aims of these sessions are to: (1) review the patient s progress and reinforce success and continued effort; (2) remind the patient of the problem solving treatment model; (3) consolidate the skills for the problem-solving strategy; (4) gradually increase the patient's independence in conducting problem-solving; and (5) facilitate a positive problem-solving attitude. The patient and therapist should review the original problems, consider progress, and always be prepared to add new problems to the problem list. At this point, the patient may have worked through a series of short and mid-range goals to reach a longterm goal. For example, if the final goal was to secure a new job, the short-term and intermediate goals may have been: (1) to obtain information about the qualifications required; (2) to send application forms; and (3) to attend an interview. For goals such as these, which are achieved in phases, the therapist should encourage continued effort over time and track progress as each phase progresses.
Materials for Sessions 3 through 5: Provide the patient with: Session 3: (1) PST-PC Worksheet (With therapist guidance, patient fills out in session using own copy) (2) Extra PST-PC Worksheet Session 4: (1) PST-PC Worksheet (Fill out with therapist if necessary, but the patient ideally takes the lead in filling out) (2) Extra PST-PC Worksheet Session 5: (1) PST-PC Worksheet (Patient fills out in session; with assistance if necessary) (2) Extra PST-PC Worksheet SESSION 6: Time: 30 minutes. The aims for this session are to: (1) review the patient s progress and reinforce success and continued effort; (2) remind the patient of the problem solving treatment model; (3) comment on the remaining problems from the problem list and encourage the patient to continue their problem solving efforts in the future; (4) begin to anticipate upcoming situations for potential or hypothetical problems in the future;
(5) review and emphasize the problem-solving process, with emphasis on it being something the patient has learned and can now effectively apply independently of the therapist; (6) agree on follow-up plans if necessary; (7) facilitate a positive problem-solving attitude and optimism toward the future. Materials for Session 6: Provide the patient with: (1) PST-PC Worksheet (Patient fills out in session; with assistance if necessary) (2) Multiple copies of the PST-PC Worksheet Termination Issues: In Session 1 the therapist explains that the treatment will be limited to a specific number of sessions that will be provided over a specific number of weeks. Both the therapist and patient should keep this information in mind throughout treatment in anticipation of, and in planning for termination. As sessions progress the therapist should make a point of reminding the patient which session number they are undertaking and the number of treatment sessions remaining, such as Okay Mrs. Smith, today is our third problem solving visit and we have three remaining. Throughout treatment the therapist should emphasize that problem solving can be used not only for current problems, but also for future problems. The therapist should reiterate that the goal of PST-PC is not necessarily to solve all of the patient s problems but to teach them the problem solving approach so that they can apply it independently in their lives. In later sessions the therapist should gradually become less active in the
problem solving process, turning over more responsibility to the patient for conducting the session, and this change should be made apparent and emphasized to the patient. For example, the therapist may say, Okay Mrs. Smith, this is our third session and you are starting to catch on to the problem solving strategy. The purpose of our visits is to teach you the problem solving strategy so I would like to have you take a little more of a leading role in guiding the session. So, could you please tell me, what is the first step you need to take in starting to solve this problem with your boss? The therapist should always be ready to provide the patient with appropriate cues and prompts to assist them, but then again return control of the session back to the patient. The therapist should lead off Session 6 with the reminder, This is our final session. The therapist should review the problem list and identify any problems that should be considered in the final session. If additional problems have emerged there is not adequate time to fully address them in the session. The patient should be reminded of the steps they can go through to resolve them, and time may allow for problem definition and possibly goal setting, and the patient should then be encouraged and reassured by the therapist that they are now well suited to tackle this and future problems on their own. If treatment has been successful the patient should feel convinced that they have contributed to their own recovery, with the use of commonsense problem solving techniques. Achievements during treatment should be summarized so that the patient leaves with a good feeling about the work they have done. If the message regarding the primacy of the patient's own effort has been delivered throughout the treatment, then problems with termination and dependency should be minor.